Fragmented QRS can predict severity of aortic stenosis

Prevalence of electrocardiographic markers associated with myocardial fibrosis in masters athletes: a cohort study

Objectives

Myocardial fibrosis (MF) is associated with an increased predisposition to adverse cardiac events. The accumulation of high-volume and high-intensity exercise over an extended duration potentially increases the risk of MF. Specific electrocardiographic markers have been correlated with the presence of MF. This study assessed the prevalence of MF-related electrocardiographic markers in a Track and Field Master Athletics Cohort (TaFMAC).

Methods

Twelve-lead resting electrocardiograms (ECGs) were conducted on 155 athletes (90 males and 65 females) participating in the World Masters Athletics 2022. The ECG markers associated with MF, including pathological Q waves, inverted T waves, fragmented QRS complex, and prolonged QRS complex, were compared among different athletic specialities (endurance athletes n=51, sprinters n=69 and strength and power n=35).

Results

Overall, 71 instances of MF-related markers were identified from 155 ECG recordings (46%). Fragmented QRS emerged as the most common marker, with a prevalence of 29% in endurance and strength and power athletes, and 35% in sprinters. No significant group differences were observed in the prevalence of MF markers, whether analysed collectively (p=0.467) or individually (pathological Q waves p=0.367, inverted T waves p=0.309, fragmented QRS complex p=0.747 and prolonged QRS complex p=0.132).

Conclusions

The prevalence of MF markers, as determined by resting ECG, was evident in nearly half of masters athletes, irrespective of sex and sporting specialisation. These findings suggest resting ECG as a promising non-invasive method for the early identification of MF in athlete's hearts.

Fragmented QRS as a predictor of hypertensive crisis in patients with newly diagnosed essential hypertension: 4-year follow-up data

BACKGROUND

Hypertensive crisis (HC) is a life-threatening condition in patients with hypertension (HT). However, there is no electrocardiography (ECG) marker that can predict which hypertensive patient may develop HC. The fragmented QRS (fQRS) complex is an important prognostic marker in ECG that might be predict cardiovascular events and mortality. Our study aimed to investigate whether fQRS can predict the development of HC in patients with HT, within 4 years of follow-up.

METHODS

Newly diagnosed patients with essential HT were recruited for the study from an outpatient clinic. The patients were divided into two groups according to the presence of HC: HC (+) and HC (-). During follow-up, the relationship between fQRS and HC was evaluated.

RESULTS

The study group included 504 patients with newly diagnosed HT. During the follow-up period, HC occurred in 98 of the patients. In 57 (11.30%) patients, fQRS was observed on ECG; fQRS was detected in the ECG of 19 (19.38%) of the HC (+) patients (p = 0.008). The results of multivariate logistic regression analysis showed that fQRS (p < 0.001) was as independent predictor for HC development. Kaplan-Meier analysis further demonstrated that the presence of fQRS affects the development of hypertensive urgency in hypertensive patients (log-rank p < 0.001).

CONCLUSION

In patients with newly diagnosed HT, the presence of fQRS was found to be an independent predictor of HC.

Electrocardiographic Markers of Adverse Left Ventricular Remodeling and Myocardial Fibrosis in Severe Aortic Stenosis

The optimal timing for aortic valve replacement (AVR) in aortic stenosis (AS) is still controversial and may be guided by markers of adverse left ventricular (LV) remodeling. We aim to assess electrocardiographic (ECG) strain in relation to LV remodeling and myocardial fibrosis. 83 severe AS patients underwent surgical AVR, with preoperative 12-lead ECG, cardiovascular magnetic resonance with T1 mapping and echocardiography with global longitudinal strain analysis. Collagen volume fraction (CVF) was measured in myocardial biopsies sampled during AVR. Patients with ECG strain had more severe AS, more advanced LV remodeling and evidence of heart failure. Patients with ECG strain had more diffuse fibrosis, as evident by higher mean native T1 values (974.8 ± 34 ms vs. 946.5 ± 28 ms, p < 0.001). ECG strain was the only predictor of increased LV mass index on multivariate regression analysis (OR = 7.10, 95% CI 1.46-34.48, p = 0.02). Patients with persistent ECG strain at 1 year following AVR had more advanced LV remodeling and more histological fibrosis (CVF 12.5% vs. 7.3%, p = 0.009) at baseline assessment. Therefore, ECG strain is a marker of adverse LV remodeling and interstitial myocardial fibrosis. Lack of improvement in ECG strain following AVR indicates more advanced baseline LV injury and higher levels of myocardial fibrosis.

Fragmented QRS complex may predict long-term mortality after isolated surgical aortic valve replacement in patients with severe aortic stenosis

OBJECTIVES

Fragmented QRS (fQRS), related to myocardial fibrosis, is an important prognostic marker of cardiovascular events and mortality. Aortic stenosis (AS), the most frequent valvular heart disease in developed countries, causes myocardial fibrosis due to ventricular pressure overload. The current study aimed to investigate whether fQRS is associated with long-term mortality after isolated surgical aortic valve replacement (SAVR) in patients with severe AS.

METHODS

A total of 289 patients who underwent SAVR for severe AS between May 2009 and January 2020 with interpretable electrocardiogram were included. Patients were divided into 2 groups according to the presence of fQRS. Kaplan-Meier survival analyses were used to detect cumulative survival rates. Univariable and multivariable Cox proportional hazards models were used to determine the predictors of all-cause mortality.

RESULTS

fQRS occurred in 126 (43.5%) patients. A total of 59 (20.4%) patients died over a follow-up period of 54 ± 32 months. All-cause mortality was higher in the fQRS group (23 [14.1%] vs 36 [28.6], log-rank test P = 0.002) in the long term. The presence of fQRS [hazard ratio (HR): 1.802, confidence interval (CI): 1.035-3.135, P = 0.037], electrocardiographic left ventricular strain (HR: 1.836, CI: 1.036-3.254, P = 0.038) and history of stroke or transient ischaemic attack (HR: 3.130, CI: 1.528-6.412, P = 0.002) were independent predictors of all-cause mortality in the multivariable Cox regression model.

CONCLUSIONS

fQRS is associated with a 1.8-fold increase in long-term mortality in patients undergoing isolated SAVR for severe AS. Detecting fQRS in electrocardiograms may provide prognostic information about the long-term outcomes.

Role of QRS fragmentation in 12-lead surface ECG in prediction of isolated epicardial coronary artery ectasia and its anatomical distribution in patients without acute coronary syndromes

Background

Coronary artery ectasia (CAE) is a form of abnormal coronary artery lumen dilatation associated with epicardial flow disturbances and microvascular dysfunction. QRS complex fragmentation (fQRS) in surface ECG is caused by abnormal depolarization due to myocardial ischemia and scarring. It has been proved in different studies to be positively correlated with adverse cardiac events. This study aimed to assess the role of fQRS as a non-invasive predictor of CAE and its anatomical distribution. A total of 100 patients referred for elective coronary angiography were included and divided into 2 groups: 50 patients with isolated CAE (group A) and 50 patients with angiographically normal coronaries (group B, control group). Both groups were compared regarding clinical, echocardiographic, and ECG characteristics.

Results

Univariate analysis showed a significant correlation between male sex, smoking, diabetes mellitus, increased systolic blood pressure, fQRS, echocardiographic evidence of diastolic dysfunction, and CAE (P values of 0.005, 0.002, 0.016, 0.027, 0.0001, and 0.04, respectively). Multivariate regression analysis showed that fQRS is the most important independent predictor for the presence of CAE (P < 0.00001) with sensitivity 94%, specificity 88%, PPV 88.7%, and NPV 93.6%. We also found a significant correlation between fQRS distribution in surface ECG and anatomical distribution of CAE [increased territories with multivessel affection (P = 0.00001), anterior leads with LAD affection (P = 0.00001), lateral and inferior leads with LCX affection (P = 0.003 and 0.04, respectively), inferior leads with RCA affection (P = 0.00001)].

Conclusion

fQRS in surface ECG can potentially be used as an effective non-invasive method to predict isolated CAE and its anatomical distribution.

Serum copeptin might improve risk stratification and management of aortic valve stenosis: a review of pathophysiological insights and practical implications

Over recent decades, the prevalence of aortic valve stenosis (AVS) has been constantly increasing possibly owing to the aging of general population. Severe AVS as determined by an aortic valve area (AVA) of <1 cm² has been regarded as a serious clinical condition potentially associated with a variety of adverse outcomes, including sudden cardiac death (SCD). However, patients with severe AVS (in the absence of overt high-risk features) are usually evaluated and managed exclusively based on symptomatology or imperfect prognostic tools including exercise testing and biomarkers, with a potential risk of mismanagement, suggesting the need for further objective risk stratifiers in this setting.

Within this context, copeptin (C-terminal pro-vasopressin), a novel neurohormone widely considered as the surrogate marker of the arginine–vasopressin (AVP) system, may potentially serve as a reliable prognostic and therapeutic guide (e.g. timing of aortic valvular intervention) in patients with severe AVS largely based on its hemodynamic, fibrogenic as well as autonomic implications in these patients. Accordingly, the present paper aims to discuss clinical and pathophysiological implications of copeptin in the setting of AVS along with a summary of biomarkers and other prognostic tools used in this setting.

The prognostic value of fragmented QRS in patients undergoing transcatheter aortic valve implantation

BACKGROUND

Although transcatheter aortic valve implantation (TAVI) can successfully correct aortic narrowing, pre-existing pathophysiological alterations in the left ventricle are still a concern in terms of long-term mortality. This study aimed to examine the predictive role of fQRS morphology on long-term prognosis in patients undergoing TAVI due to severe aortic stenosis.

METHODS

A total of 117 patients undergoing TAVI due to severe aortic stenosis were included in this retrospective cohort study. Patients were assigned into two groups based on the presence (n = 36) or absence (n = 81) of fQRS. Predictors of long-term survival were estimated.

RESULTS

In-hospital mortality was higher in fQRS group (5.5% vs. 1.2%, p = 0.0224). In the long-term, fQRS (OR: 3.06, 95% CI 1.29-7.27, p: 0.01), LVEF <50% (OR: 2.54, 95% CI 1.07-6.02, p: 0.03) and presence of atrial fibrillation (OR: 2.42, 95% CI 1.05-5.60, p: 0.03) emerged as significant independent predictors of short survival.

CONCLUSION

Presence of fQRS on ECG, an indirect indicator of myocardial fibrosis, seems to have the potential to be used as a prognostic marker after TAVI procedure. Large prospective studies are warranted.

Could fragmented QRS predict mortality in aortic stenosis patients after transcatheter aortic valve replacement?

BACKGROUND

Fragmented QRS evaluated in 12-derivation electrocardiography has widely been accepted as a sign of myocardial fibrosis. The prognostic value of that marker has been demonstrated, particularly, in cardiac diseases that accompany myocardial scar and fibrosis. Myocardial fibrosis is also an issue in patients with aortic stenosis. In this study, we wanted to determine whether fragmented QRS could predict all-cause mortality in aortic stenosis patients after transcatheter aortic valve replacement (TAVR).

METHOD

In this study, we evaluated a total of 116 eligible patients on whom we performed TAVR between 2014 and 2018. Patients' demographic and clinical findings, echocardiography results, in-hospital and 30-day mortality, long-term survival statuses were noted. Patient's ECGs before the procedure were evaluated in regard to the occurrence of fragmented QRS. Predictors of mortality were evaluated using univariable and multivariable Cox regression analysis.

RESULTS

The study population consisted of 116 patients of median age 79 (IQR 75-83), 64 females (55.2%). Mortality occurred in 27 (23%) patients; median follow-up time was 319 (IQR 122-719) days. Fragmented QRS was observed in 44 out of 116 (37.9%) patients. The presence of a fragmented QRS (HR = 2.178, 95% CI 0.999-4.847, p = 0.050), a history of stroke (HR = 3.463, 95% CI 1.276-9.398, p = 0.015), and the creatinine levels at admission (HR = 2.198, 95% CI 1.068-4.520, p = 0.030) were associated with the long-term mortality in multivariable Cox regression analysis.

CONCLUSION

Like in the case of the other diseases associated with myocardial fibrosis, fragmented QRS could also predict mortality in aortic stenosis patients after TAVR procedure.

Electrocardiographic appearance of aortic stenosis before and after aortic valve replacement

BACKGROUND

So far, the specific appearance of QRS complex, ST-segment, and T wave was observed in aortic stenosis (AS). S-wave dynamic change in leads V₁ -V₃ was not reported in AS.

METHODS

In a single-center, prospective study, we included a total number of 1.175 patients who underwent surgical aortic valve replacement (AVR). We conducted 3-year gathering of patients with symptomatic and asymptomatic severe AS, and separated them by hemodynamic stability into groups A and B, through EFLV (of more or less than 50%), AVA (of more or less than 0.9 cm² ), PG (between 55 and 75 mm Hg or over 75 mm Hg), and end-diastolic LV dimension (of more or less than 56 mm). We evaluated the impact of S-wave magnitude in right precordial leads before and after AVR in all patients. We followed S-wave changes in electrocardiogram altogether with hemodynamic measurements derived from echocardiography.

RESULTS

Analysis of echocardiographic parameters, measured in patients before surgery, did not show statistical significance between asymptomatic and symptomatic group. The statistical significance was observed in the change in S-wave magnitude in the right precordial leads in both subsets of patients before AVR. We found statistically significant predictive value of S-wave magnitude in leads V₂ -V₃ for dependent variables PG and end-diastolic LV dimension.

CONCLUSIONS

S-wave changes in right precordial leads can predict increase in PG and critical narrowing of AVA, suggestive of timely referral for AVR.

Evaluation of Tp-E Interval and Tp-E/QT Ratio in Patients with Aortic Stenosis

BACKGROUND

The risk of syncope and sudden cardiac death due to ventricular arrhythmias increased in patients with aortic stenosis (AS). Recently, it was shown that Tp-e interval, Tp-e/QT, and Tp-e/QTc ratio can be novel indicators for prediction of ventricular arrhythmias and mortality. We aimed to investigate the association between AS and ventricular repolarization using Tp-e interval and Tp-e/QT ratio.

METHODS

Totally, 105 patients with AS and 60 control subjects were enrolled to this study. The severity of AS was defined by transthoracic echocardiographic examination. Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios were measured from the 12-lead electrocardiogram.

RESULTS

Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios were significantly increased in parallel to the severity of AS (P < 0.001, P = 0.001, and P = 0.001, respectively). Also, it was shown that Tp-e/QTc ratio had significant positive correlation with mean aortic gradient (r = 0.192, P = 0.049). In multivariate logistic regression analysis, Tp-e/QTc ratio and left ventricular mass were found to be independent predictors of severe AS (P = 0.03 and P = 0.04, respectively).

CONCLUSIONS

Our study showed that Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios were increased in patients with severe AS. Tp-e/QTc ratio and left ventricular mass were found as independent predictors of severe AS.